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Edinburgh & Lothians Equal Opportunities Monitoring Form

Regional Equality Council

About this form

Edinburgh and Lothians Regional Equality Council is an equal opportunities organisation.
The information requested below is for monitoring purposes only. Completion of the form is
optional, but the information will help and improve our equal opportunities policy.
This information will be held confidentially and separately to your application, and will NOT be available
to those involved in the short listing process.

To fill it in please mark the relevant boxes, and if space is provided to write an answer, please write clearly in
BLOCK capitals. Feel free to leave any question that you do not wish to answer.

AGE
☐ 16-20 ☐ 21-25 ☐ 26-30 ☐31-35 ☐ 36 - 40 ☐ 41- 45 ☐ 46 - 50
☐ 51- 55 ☐ 56 - 60 ☐ 61- 65 ☐ 66 - 70 ☐ 71- 75 ☐ 76 - 80 ☐ 80+

DISABILITY
Do you consider yourself to have a disability?
Definition of disability: A physical or mental impairment which has a substantial and long term adverse effect on a person's
ability to carry out normal day to day activities. (Equalities Act 2010)
☐ Yes ☐ No
Please specify here: __________________________________________________________________
Any other information you would like to disclose: ___________________________________________

GENDER
How would you describe your gender identity?
☐ Woman ☐ Man
☐ Other gender identity
If ‘Other’, please specify here: __________________________________________________________

Is your gender identity different to the gender you were assigned at birth?
☐ Yes ☐ No
Any other information you would like to disclose: ___________________________________________

SEXUAL ORIENTATION
How would you describe your sexual orientation?
☐ Asexual ☐ Bisexual ☐ Gay ☐ Lesbian
☐ Heterosexual/Straight ☐ Pansexual ☐ Queer ☐ Questioning
☐ Other Sexual Orientation
If ‘Other’, please specify here: _________________________________________________________

Please continue on the next page

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ETHNICITY (as defined by Scotland’s 2011 Census)
Chose ONE section from A to E, then tick ONE box which best describes your ethnic group or background

A) White
☐ Scottish ☐ English ☐ Welsh ☐ Northern Irish ☐British
☐ Irish ☐ Gypsy/Traveller ☐ Polish ☐ Other
If other please specify_______________________________________________________________

B) Any mixed or multiple ethic groups

☐ Please tick and write in:____________________________________________________________

C) Asian, Asian Scottish or Asian British

☐ Pakistani, Pakistani Scottish or Pakistani British
☐ Indian, Indian Scottish or Indian British
☐ Bangladeshi, Bangladeshi Scottish or Bangladeshi British
☐ Chinese, Chinese Scottish or Chinese British
☐ Other: please tick and write in_______________________________________________________

D) African, Caribbean or Black

☐ African, African Scottish or African British
☐ Caribbean, Caribbean Scottish or Caribbean British
☐ Black, Black Scottish or Black British
☐ Other: please tick and write in_______________________________________________________

E) Other ethnic group

☐ Arab
☐ Other: please tick and write in _______________________________________________________

WHAT IS YOUR RELIGION (IF ANY)?

☐ None ☐ Buddhist ☐ Church of Scotland ☐ Christian (other)
☐ Hindu ☐ Humanist ☐ Jewish ☐ Muslim
☐ Pagan ☐ Roman Catholic ☐ Sikh ☐ Other

If ‘Other’, please specify here: _________________________________________________________

PLEASE STATE YOUR EMPLOYMENT STATUS:

☐ Employed ☐ Self Employed ☐ Student
☐ Unemployed ☐ Retired ☐ Look after home or family

Other, please specify ________________________________________________________________

WHAT IS YOUR MARITAL STATUS?

☐ Married ☐ Divorced ☐ Widowed ☐Single
☐ Living with someone ☐ Civil Partnership ☐ Separated

IF YOU HAVE CARING RESPONSIBILTIES, IS IT FOR:

☐ Children ☐ Adults ☐ Elderly

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